นศพ อรรณพ fx lt femur

Orthopedics Noon conference

นพท. อรรณพ กตตถาวรวทยาลยแพทยศาสตรพระมงกฎเกลา

History takingCase ผปวยหญงไทยค อาย 67 ป เชอชาต ไทย

สญชาตไทย ศาสนา พทธ ภมลำาเนา: จงหวด นครราชสมา อาชพ: ทำานา สทธการรกษา:หลกประกน

สขภาพถวนหนา

รบเขารกษา ในโรงพยาบาล วนท 15 พฤศจกายน 2559 เนองดวย (chief complaint): ไมสามารถเดนได 4hrs.PTA

Primary surveyA : A Thai woman able to talk, No stridor, Not

tender at C-spine, Active neck flexion

B : RR 20/min, no dyspnea , normal chest expansion ,trachea in midline, normal breath sound and equal both lungs, no ribs stepping and

tenderness, no open wound on chest wall

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Primary survey C : BP 140/73 mmHg, PR 66 bpm, Pulse full and

regular, Capillary refill <2 sec. no external active bleeding, pelvic compression test : negative

D : E4V5M6, pupils 3 mm RTLBE.

E : On splint at left leg, no open wound and active bleeding, no ecchymosis, Left leg was shortening , slightly external rotation and abduction of left leg, mild tenderness on left hip PR : not done

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Adjunct Primary Survey

• Fracture immobilizaton

Monitor :

o Monitor vital signs

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Secondary survey• A : No food/drug allergy

• M : Amlodipine(5) 2x1oral pc in the morning

• P : Hypertension

• L : Last meal at 06.00 am.

• E : 4 ชม.กอนมารพ. ขณะเกบผายางตากขาว ผปวย เดนถอยหลงสะดดและลมลง ศรษะไมกระแทก

Secondary survey• Event: 4hrs. PTA

-ขณะผปวยเกบผายางทใชตากขาวเปลอกหนาบานผปวยเดนถอยหลงจากนน

สะดดกอนอฐแลวลมลง สวนของเอวและสะโพก ขางขวากระแทรกพน ศรษะไมกระแทกพน ไมสลบ

จำาเหตการณได หลงจากนนมอาการเจบทบรเวณสะโพกขางซาย

-ผปวยสามารถพยงตวเองลกขน เดนได แตเดนในลกษณะเดนกะเผลก

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• Event: 4hrs. PTA

- ผปวยพยายามทจะเดนเขาหองนำา จากนนลน บรเวณหองนำา แตไมลมเนองจากมญาตมาชวยพยง

ไดทน หลงจากทผปวยลนผปวยรสกเสยวบรเวณตน ขาซาย ลงนำาหนกไมได เดนเองไมได และปวดบรเวณ

สะโพกซายมากขน- ปฎเสธประวตอบตเหต ชนหรอกระแทกมา

กอนหนา , ประจำาเดอนหมดตงแต อาย40 ป

Secondary survey

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Physical examination• Vital signs: Temp =37.1°C RR=20/min

BP=140/73mmHg PR=66/min

GA: An old Thai woman ,good consciousness, well cooperate, no pallor ,no jaundice

HEENT: no pale conjunctivae, anicteric sclerae

CVS: full and regular pulse, normal s1,s2 no murmur

Lungs: normal breath sound and no adventitious sound of both lungs

• Abdomen : no distension , normoactive bowel sound, no tenderness , no guarding

• Extremities : Left leg

-Inspection = no swelling, no ecchymosis , Left leg was shortening slightly external rotation and abduction of left leg

- Palpation = pain with percussion over greater trochanter

- Limit range of motion due to pain at left leg

- Anvil and Rolling test were positive at Left leg

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• Neurovascular :

o Full 2+ at Left femoral a. , Left Popliteal a. , Left posterior tibial a. and Left dorsalis pedis a.

o Normal capillary refill < 2sec

o Motor power of Left plantar flexion and dorsiflexion grade V

Pertinent findingsHistory taking

- Fall down

- Antalgic gait

- Unable to stand

- Inability to walk

- Pain in the entire Left hip

- Menopause

- No history of previous trauma

Physical examination

- Left leg was shortening - Slightly external rotation and abduction of left leg

- Pain with percussion over greater trochanter area

- Limit range of motion due to pain

- Anvil and Rolling test were positive at Left leg

- No ecchymosis

- No swelling

Shenton’s line

Film :Pelvis AP

Film :Hip AP

Film : Hip lateral

Film : Lt femur lateral

Diagnosis• Close fracture total displacement of Left femoral

neck

• Garden Classification : type IV

Fracture of neck femur

• Epidemiology• Pertinent anatomy• Pathophysiology• Mechanism of injury• Presentation• Prognosis• Garden Classification• Imaging• Treatment

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Epidemiology• increasingly common due to aging population

• women > men

• whites > blacks

• United states has highest incidence of hip fx rates worldwide

• most expensive fracture to treat on per-person basis

Pertinent anatomy• Femoral neck fractures are intracapsular

• The tenuous blood supply to the femoral neck increases the risk of complications, such as avascular necrosis

• Blood supply : major contributor is medial femoral circumflex (lateral epiphyseal artery)some contribution to anterior and inferior head from lateral

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Intracapsular versus extracapsular hip fractures

Pathophysiology• Healing potential

o femoral neck is intracapsular, bathed in synovial fluid

o lacks periosteal layero callus formation limited, which affects healing

Mechanism of injury● Femoral neck fractures tend to occur in elderly patients who fall

-A fall directly onto the lateral hip

-A twisting mechanism in which the patient's foot is planted and the body rotates

-A sudden spontaneous completion of a fatigue (or insufficiency) fracture, which then causes a fall

Mechanism of injury● In younger individuals

-Femoral neck fractures generally occur as a result of major trauma,

such as a motor vehicle collision or a fall from a height.

- Associated injuries femoral shaft fractures6-9% associated with femoral neck fractures

PresentationSymptoms

● impacted and stress fractures-slight pain in the groin or pain referred along the

medial side of the thigh and knee

●displaced fractures-pain in the entire hip region

Physical exam

● impacted and stress fractures-no obvious clinical deformity-minor discomfort with active or passive hip range of

motion, muscle spasms at extremes of motion-pain with percussion over greater trochanter

● displaced fractures- leg in external rotation and abduction, with shortening

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Prognosis• mortality

o ~25-30% at one year (higher than vertebral compression fractures)

• predictors of mortalityo pre-injury mobility is the most significant

determinant for post-operative survival o in patients with chronic renal failure, rates of

mortality at 2 years postoperatively, are close to 45%

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Garden ClassificationType I : Incomplete, ie. valgus impacted

Type II :Complete fx. Nondisplaced

Type III :Complete, partially displaced

Type IV : Complete, fully displaced

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Imaging• Radiographs

• Garden classification is based on AP pelvis• CT

o helpful in determining displacement and degree of comminution in some patients

• MRI , Bone scano helpful to rule out occult fracture 

• Duplex Scanning• rule out DVT if delayed presentation to

hospital after hip fracture 

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Treatment• Non-operative

►observation aloneo indications• may be considered in some patients who are

non-ambulators, have minimal pain, and who are at high risk for surgical intervention

• Operative ► ORIF

-Displaced fractures in young ORIF indicated for most pts <65 years of

age

Treatment• Operative ► Cannulated screw fixation

-nondisplaced transcervical fx-Garden I and II fracture patterns in the

physiologically elderly-displaced transcervical fx in young patient

Treatment• Operative

►total hip arthoplasty -older active patients >65 years of age-patients with preexisting hip osteoarthritis-Arthroplasty for Garden III and IV in patient < 85 years

Fracture neck of femur

Non-displaceme

nt

Conservative Multiple screws

Displacement

Physiologically <60-65 years

Closed reduction under x-ray

Reduction possible

Multiple screw

Reduction not

possible

Open reduction

screw fixation

Physiologically >60-65 years

Healthy ,no functional limitation or hip osteoarthritis

THA Hemi:active community

walker

Bipolar

Unipolar

yes No

yes

No

Supportive treatment• Pain control

Morphine 3 mg v prn q 6 hr

• On skin traction at Lt leg with 2 kg

• Plasil 10 mg v prn q 6 hr

• Underlying disease Amlodipine(5) 2x1oral pc in the morning

• Nutritional support low salt diet

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Complication• Osteonecrosis incidence of 10-45%

• Nonunion incidence of 5 to 30%increased incidence in displaced fractureso no correlation between age, gender, and rate

of nonunion

• Dislocation higher rate of dislocation with THA (~ 10%)

References• http://www.orthobullets.com/trauma/1037/

femoral-neck-fractures• www.uptodate.com/Hip fractures in adults ;

Katherine Walker Foster, MD: Oct 31, 2016• ธรชย อภวรรธกกล.Orthopaedic Trauma. พมพครงท

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